By Dr Jayanti Doshi

Not being able to conceive? Check out your options in the latest assisted reproductive technologies, says Ruchira Bose

Walk into Dr Jatin Shah’s infertility management clinic, and all around, you see baby pictures and jubilant smiles on parents — of various ages! It’s like a wallpaper of hope and joy. Each picture tells a story that is common and yet unique at the same time. There are women in those photos who were beaten and taunted for years by husbands and mothers-in-law because they hadn’t conceived.

Pictures of parents who had lost their only child in an accident, to disease or in the Kargil war. But if you saw the pictures, you’d never imagine the grief. So many smiling faces and so many new lives. Assisted Reproductive Technologies (ARTs) like In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI) have been like a boon for these people.

It’s estimated that one out of six couples in India is affected by infertility and has to deal with the medical, psychological and financial stresses related to their condition.

No Babies Here
Most of the time, women are the first to be accused of being infertile. But most doctors in the field say male factor infertility is more common. You are considered infertile if you are under 35 and haven’t conceived after one year of trying with unprotected sex or if you are over 35 and have tried for six months.

Any of the following could cause infertility:
For women:
* Ovulatory disorders include infrequent, irregular or complete absence of periods. Which means your eggs are not develop-ed or are not released. This could be due to an eating disorder, hormonal imbalance, excessive exercise, thyroid dysfunction, insulin resistance, etc.
* Nearly half of all female infertility cases can be traced to Polycystic Ovarian Disorder (PCOD). It implies that there may be cysts and pockets of undischarged menstrual blood that create a toxic environment in your uterus.
* Your fallopian tubes may be blocked or damaged. From ages 30 to 35, the chances of becoming pregnant and carrying to full term gradually decline and after 40, there is a sharp decline. Irregular ovulation, fewer eggs, endometriosis, hormonal imbalances and resistence to fertilisation are some of the issues that crop up. Chances of miscarriage and chromosomal abnormalities and birth defects such as Down Syndrome, are also higher. IVF and ICSI also get less successful with age.

Male Factors include low sperm motility, bad quality sperm, sexual intercourse problems, or blocked vas deferense (the organ that carries the sperm from the testes to the penis). Male infertility factors have been on a steep rise lately because of rising levels of oestrogen in food due to the use of fertilisers and pesticides.

The IVF Route
Normally, the woman produces one egg per cycle. The egg matures and is released by the follicle from the ovaries. It travels through the fallopian tube to the uterus where, if it gets fertilised by a sperm, it becomes an embryo and attaches itself to the uterus wall and takes nine months to mature completely.

For IVF, doctors give hormones, either by injections or inhalers, to stimulate the ovaries to produce and mature several eggs in one cycle. Once these eggs mature, they are collected with the help of transvaginal ultrasound guidance. No hospitalisation is required as the procedure takes a couple of hours and you’re good to go once it’s over. Ultrasound-guided egg retrieval has made the most physically demanding part of the IVF procedure in the past (laparoscopy) less traumatic.

Next, the sperm is collected from the husband (by masturbation). Each egg is placed in a petri dish along with thousands of sperms in a nutritive fluid. The dish is placed in temperature-controlled incubators in a vacuum-sealed room. Whether in a petri dish or in the uterus, it takes 10,000 to 20,000 sperms to keep working on a single egg for over six hours before one finally breaks through.

The fertilised eggs are allowed to develop for one or two days more in the lab before they are placed inside the woman‘s uterus. Depending on the couple‘s wishes, in some centres, some fertilised eggs may be frozen and stored for future use.

A pregnancy test is done 12 to 14 days after the transfer. If it is positive, it’s considered a ‘precious pregnancy’ but apart from close monitoring, there is no special care beyond what is suggested during any normal pregnancy.

The ICSI route
Less than a decade ago, treatment for a male factor was limited to inseminations or IVF using donor sperm. Today, the success rates for direct sperm injection (ICSI) are comparable to or even better than those for non-male factor patients. This technique injects the sperm right inside the egg. Remarkably, once the injecting pipette is withdrawn, the egg closes and assumes its original shape within 60 seconds. The skill of the technician is a critical factor in the success of the ICSI process. Some doctors invest extra in high-tech precision equipment. “My clinic’s in an old residential building, if someone’s grinding spices upstairs and the vibrations come through, the needle can damage the egg! I’d rather invest a couple of lakhs in a vibration-proof table than damage an egg,” says Dr Shah.

One Too Many
The transfer of several embryos increases the probability of success, but simultaneously ups the risk of multiple pregnancies. About 20 to 25 per cent of pregnancies with IVF will be a multiple pregnancy. Most of these will be twins. Triplets, or quadruplets can occur, but most doctors suggest removal of some of the embryos in such cases as this decreases the chance of miscarriages, premature labour or pregnancy-induced high blood pressure and diabetes.

“Overseas, if a couple wanted only one child and they conceived twins or triplets, they would ask the doctor to leave one embryo and retrieve the others. But here, many see it as ‘buy one, get one free’. I insist if my patient has conceived more than twins, the other embryos should be retrieved so that there is no danger to the pregnancy.’’

Risk Of Breast Cancer
An increased risk of breast cancer is associated with ARTs, due to the hormone injections, but most doctors in India suggest a max of six cycles (as opposed to doctors in the US who suggest nine to 12 cycles), which reduces your risk. Also, the patient and her family history are studied to determine risks and the dosage of hormones is always case specific.

And now, with In vitro Maturation (IVM), a break-through in ARTs, each egg is matured outside the ovaries, in controlled lab conditions. The hormones are added directly to the egg, so none of the side effects associated with hormone intake occurs in the woman.

Choose A Clinic
As ARTs are high-precision procedures and fairly expensive, don’t be embarrassed to check the credentials of the infertility doctor you are considering. Find out about success rates, take a guided tour of the facility and ask your doctor to familiarise you with the whole process.

Myths Busted
‘IVF increases risks of birth defects or premature births.’
There is no evidence of this. Most IVF clinics don't consider IVF pregnancies high risk, except for the risk of early miscarriage, for which many provide progesterone supplements to help maintain the pregnancy to term. A woman has the same pregnancy risks with IVF as any woman her age who has conceived normally.

‘IVF implies that it’s not my baby.’
In 90 per cent cases, the couple uses their own egg and sperm. If a donor is required, as there is no legal stand on it, doctors suggest the couple brings a donor from within the family.

‘It’s a very expensive procedure with low success rates.’
On an average, each cycle costs Rs 70,000 to Rs 80,000. Usually doctors suggest three to five cycles. There are clinics today that boast a success rate of 55 per cent full-term pregnancies with just one or two cycles.

‘IVF is a last resort.’
Today, it’s considered first line of therapy as it has high rates of success and it reduces the trauma and expense associated with ‘trials’.

Disclaimer: This feature is meant to help you make informed choices about addressing infertility. Femina does not advocate or take a stand on IVF and other assisted reproductive technologies.
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